Individual
MI LA SEO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
500 JEFFERSON ST, WHITEVILLE, NC 28472
(910) 642-1776
(910) 642-9305
Mailing address
PO BOX 602530, CHARLOTTE, NC 28260-2530
(910) 642-1776
(910) 642-9305
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
2009-01535
NC
207R00000X
Internal Medicine Physician
Primary
286138
NY
207R00000X
Internal Medicine Physician
39828
KY
207R00000X
Internal Medicine Physician
MD27578
OR
208M00000X
Hospitalist Physician
MD27578
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000387452
ANTHEM BCBS
KY
05
—
1568425452
—
NC
05
—
NC1970
—
SC
Enumeration date
04/11/2006
Last updated
03/25/2021
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